Introduction. Tendon ruptures are a common injury and often require surgical intervention to heal. A refixation is commonly performed with high-strength suture material. However, slipping of the thread is unavoidable even at 7 knots potentially leading to reduced compression of the sutured tendon at its footprint. This study aimed to evaluate the biomechanical properties and effectiveness of a novel dynamic high-strength suture, featuring self-tightening properties. Method. Distal biceps tendon rupture tenotomies and subsequent repairs were performed in sixteen paired human forearms using either conventional or the novel dynamic high-strength sutures in a paired design. Each tendon repair utilized an intramedullary biceps button for radial fixation. Biomechanical testing aimed to simulate an aggressive postoperative rehabilitation protocol stressing the repaired constructs. For that purpose, each specimen underwent in nine sequential days a daily mobilization over 300 cycles under 0-50 N loading, followed by a final destructive test. Result. After the ninth day of cyclic loading, specimens treated with the dynamic suture exhibited significantly less tendon elongation at both proximal and distal measurement sites (-0.569±2.734 mm and 0.681±1.871 mm) compared to the conventional suture group (4.506±2.169 mm and 3.575±1.716 mm), p=0.003/p<0.002. Gap formation at the bone-tendon interface was significantly lower following suturing using dynamic suture (2.0±1.6 mm) compared to conventional suture (4.5±2.2 mm), p=0.04. The maximum load at failure was similar in both treatment groups (dynamic suture: 374± 159 N; conventional suture: 379± 154 N), p=0.925. The predominant failure mechanism was breakout of the button from the bone (dynamic suture: 5/8; conventional suture: 6/8), followed by suture rupturing, suture unraveling and tendon cut-through. Conclusion. From a biomechanical perspective, the novel dynamic high-strength suture demonstrated higher resistance against gap formation at the bone tendon interface compared to the conventional suture, which may contribute to better postoperative tendon integrity and potentially quicker functional recovery in the clinical setting

The February 2023 Shoulder & Elbow Roundup. 360. looks at: Arthroscopic capsular release or manipulation under anaesthesia for frozen shoulder?; Distal biceps repair through a single incision?; Distal biceps tendon ruptures: diagnostic strategy through physical examination; Postoperative multimodal opioid-sparing protocol vs standard opioid prescribing after knee or shoulder arthroscopy: a randomized clinical trial; Graft healing is more important than graft technique in massive rotator cuff tear; Subscapularis tenotomy versus peel after anatomic shoulder arthroplasty; Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty; Conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty

The December 2022 Shoulder & Elbow Roundup. 360. looks at: Biceps tenotomy versus soft-tissue tenodesis in females aged 60 years and older with rotator cuff tears; Resistance training combined with corticosteroid injections or tendon needling in patients with lateral elbow tendinopathy; Two-year functional outcomes of completely displaced midshaft clavicle fractures in adolescents; Patients who undergo rotator cuff repair can safely return to driving at two weeks postoperatively; Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures; Treatment of acute distal biceps tendon ruptures; Rotator cuff tendinopathy: disability associated with depression rather than pathology severity; Coonrad-Morrey total elbow arthroplasty implications in young patients with post-traumatic sequelae

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Aims. The conventionally described mechanism of distal biceps tendon rupture (DBTR) is of a ‘considerable extension force suddenly applied to a resisting, actively flexed forearm’. This has been commonly paraphrased as an ‘eccentric contracture to a flexed elbow’. Both definitions have been frequently used in the literature with little objective analysis or citation. The aim of the present study was to use video footage of real time distal biceps ruptures to revisit and objectively define the mechanism of injury. Methods. An online search identified 61 videos reporting a DBTR. Videos were independently reviewed by three surgeons to assess forearm rotation, elbow flexion, shoulder position, and type of muscle contraction being exerted at the time of rupture. Prospective data on mechanism of injury and arm position was also collected concurrently for 22 consecutive patients diagnosed with an acute DBTR in order to corroborate the video analysis. Results. Four videos were excluded, leaving 57 for final analysis. Mechanisms of injury included deadlift, bicep curls, calisthenics, arm wrestling, heavy lifting, and boxing. In all, 98% of ruptures occurred with the arm in supination and 89% occurred at 0° to 10° of elbow flexion. Regarding muscle activity, 88% occurred during isometric contraction, 7% during eccentric contraction, and 5% during concentric contraction. Interobserver correlation scores were calculated as 0.66 to 0.89 using the free-marginal Fleiss Kappa tool. The prospectively collected patient data was consistent with the video analysis, with 82% of injuries occurring in supination and 95% in relative elbow extension. Conclusion. Contrary to the classically described injury mechanism, in this study the usual arm position during DBTR was forearm supination and elbow extension, and the muscle contraction was typically isometric. This was demonstrated for both video analysis and ‘real’ patients across a range of activities leading to rupture. Cite this article: Bone Jt Open 2022;3(10):826–831

Aims

Acute distal biceps tendon repair reduces fatigue-related pain and minimizes loss of supination of the forearm and strength of flexion of the elbow. We report the short- and long-term outcome following repair using fixation with a cortical button techqniue.

Aims. The aim of this systematic review and meta-analysis is to evaluate differences in functional outcomes and complications between single- (SI) and double-incision (DI) techniques for the treatment of distal biceps tendon rupture. Methods. A comprehensive search on PubMed, MEDLINE, Scopus, and Cochrane Central databases was conducted to identify studies reporting comparative results of the SI versus the DI approach. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for search strategy. Of 606 titles, 13 studies met the inclusion criteria; methodological quality was assessed with the Newcastle-Ottawa scale. Random- and fixed-effects models were used to find differences in outcomes between the two surgical approaches. The range of motion (ROM) and the Disabilities of the Arm, Shoulder and Hand (DASH) scores, as well as neurological and non-neurological complications, were assessed. Results. A total of 2,622 patients were identified. No significant differences in DASH score were detected between the techniques. The SI approach showed significantly greater ROM in flexion (standardized mean difference (SMD) -0.508; 95% confidence interval (CI) -0.904 to -0.112) and pronation (SMD -0.325, 95% CI -0.637 to -0.012). The DI technique was associated with significantly less risk of lateral antebrachial cutaneous nerve damage (odds ratio (OR) 4.239, 95% CI 2.171 to 8.278), but no differences were found for other nerves evaluated. The SI group showed significantly fewer events of heterotopic ossification (OR 0.430, 95% CI 0.226 to 0.816) and a lower reoperation rate (OR 0.503, 95% CI 0.317 to 0.798). Conclusion. No significant differences in functional scores can be expected between the SI and DI approaches after distal biceps tendon repair. The SI approach showed greater flexion and pronation ROM and a lower risk of heterotopic ossification and reoperation. The DI approach was favourable in terms of lower risk of neurological complications. Cite this article: Bone Joint J 2020;102-B(12):1608–1617

Compared to single-incision distal biceps repair (SI), double-incision repair (DI) theoretically allows for reattachment of the tendon to a more anatomically favorable position. We hypothesized that DI repair would result in greater terminal supination torque compared to SI repair for acute distal biceps ruptures. In this retrospective cohort study, patients were included if they sustained an isolated, acute (° supinated position. Secondary outcomes included supination torque in 45° supinated, neutral, and 45° pronated positions, ASES elbow score, DASH, SF-12, and VAS. Power analysis revealed that at least 32 patients were needed to detect a minimum 15% difference in the primary outcome (β = 0.20). Statistical analysis was performed with significance level α = 0.05 using R version 3.4.1 (R Core Team 2017, Vienna, Austria). Of 53 eligible patients, 37 consented to participate. Fifteen were repaired using DI technique and 22 using SI technique. Mean age was 47.3yrs and median follow-up time was 28.1months. The groups did not differ with respect to age, time-to-follow-up, dominance of arm affected, Workers Compensation or smoking status. Mean supination torque, measured as the percentage of the unaffected side, was 60.9% (95%CI 45.1–76.7) for DI repair versus 80.4% (95%CI 69.1–91.7) for SI repair at the 60°supinated position (p=0.036). There were no statistically significant differences in mean supination torque at the 45°supinated position: 67.1% (95%CI 49.4–84.7) for DI versus 81.8% (95%CI 72.2–91.4) for SI (p=0.102), at the neutral position: 88.8% (95%CI 75.2–102.4) for DI versus 97.6% (95%CI 91.6–103.7) for SI (p=0.0.170), and at the 45°pronated position: 104.5% (95%CI 91.1–117.9) for DI versus 103.4 (95%CI 97.2–109.6) for SI (p=0.0.862). No statistically significant differences were detected in the secondary outcomes ASES Pain, ASES Function, DASH scores, SF-12 PCS or MCS, or VAS Pain. A small difference was detected in VAS Function (median 1.3 for DI repair versus 0.5 for SI repair, p=0.023). In a multivariate linear regression model controlling for arm dominance, age, and follow-up time, SI repair was associated with a greater mean supination torque than DI repair by 19.6% at the 60°supinated position (p=0.011). Contrary to our hypothesis, we found approximately a 20% mean improvement in terminal supination torque for acute distal biceps ruptures repaired with the single-incision technique compared to the double-incision technique. Patients uniformly did well with either technique, though we contend that this finding may have clinical significance for the more discerning, high-demand patient

Compared to single-incision distal biceps repair (SI), double-incision repair (DI) theoretically allows for reattachment of the tendon to a more anatomically favorable position. We hypothesized that DI repair would result in greater terminal supination torque compared to SI repair for acute distal biceps ruptures. In this retrospective cohort study, patients were included if they sustained an isolated, acute (° supinated position. Secondary outcomes included supination torque in 45° supinated, neutral, and 45° pronated positions, ASES elbow score, DASH, SF-12, and VAS. Power analysis revealed that at least 32 patients were needed to detect a minimum 15% difference in the primary outcome (β = 0.20). Statistical analysis was performed with significance level α = 0.05 using R version 3.4.1 (R Core Team 2017, Vienna, Austria). Of 53 eligible patients, 37 consented to participate. Fifteen were repaired using DI technique and 22 using SI technique. Mean age was 47.3yrs and median follow-up time was 28.1months. The groups did not differ with respect to age, time-to-follow-up, dominance of arm affected, Workers Compensation or smoking status. Mean supination torque, measured as the percentage of the unaffected side, was 60.9% (95%CI 45.1–76.7) for DI repair versus 80.4% (95%CI 69.1–91.7) for SI repair at the 60°supinated position (p=0.036). There were no statistically significant differences in mean supination torque at the 45°supinated position: 67.1% (95%CI 49.4–84.7) for DI versus 81.8% (95%CI 72.2–91.4) for SI (p=0.102), at the neutral position: 88.8% (95%CI 75.2–102.4) for DI versus 97.6% (95%CI 91.6–103.7) for SI (p=0.0.170), and at the 45°pronated position: 104.5% (95%CI 91.1–117.9) for DI versus 103.4 (95%CI 97.2–109.6) for SI (p=0.0.862). No statistically significant differences were detected in the secondary outcomes ASES Pain, ASES Function, DASH scores, SF-12 PCS or MCS, or VAS Pain. A small difference was detected in VAS Function (median 1.3 for DI repair versus 0.5 for SI repair, p=0.023). In a multivariate linear regression model controlling for arm dominance, age, and follow-up time, SI repair was associated with a greater mean supination torque than DI repair by 19.6% at the 60°supinated position (p=0.011). Contrary to our hypothesis, we found approximately a 20% mean improvement in terminal supination torque for acute distal biceps ruptures repaired with the single-incision technique compared to the double-incision technique. Patients uniformly did well with either technique, though we contend that this finding may have clinical significance for the more discerning, high-demand patient

This is largest collection of outcomes of distal biceps reconstruction in the literature. 8 subjects prospectively measured pre and post reconstruction Strength deficit in patients with chronic tendon deficit is described. To describe outcomes for 53 chronic distal biceps reconstructions with tendon graft. Clinical outcomes as well as strength and endurance in supination and flexion are reported. To examine eight patients measured pre- and post-reconstruction. To identify deficit in supination and flexion in chronic reconstruction. 53 reconstructions of chronic distal biceps with tendon graft were carried out between 1999 and 2015. 26 subjects agreed to undergo strength testing after minimum one year follow up. Eight subjects were tested both before and after reconstruction. Primary outcomes were strength in elbow flexion and forearm supination. Strength testing of supination and flexion included maximum isokinetic power and endurance performed on a Biodex. Clinical outcomes measures included pre-operative retraction severity, surgical fixation technique, postoperative contour, range of motion, subjective satisfaction, SF-12, DASH, MAYO elbow score, ASES and pain VAS Non-parametric data was reported as median (interquartile range), while normally-distributed data was reported as mean with 95% Confidence Limits. Hypothesis testing was performed according to two-tailed, paired t-tests. Median time from index rupture to reconstructions 9.5 (range 3–108) months. Strength measurements were completed at a median follow-up time of 29 (range 12–137) months on 26 subjects. The proportion of patients that achieved 90% strength of the contralateral limb post-reconstruction was 65% (17/26) for peak supination torque, and 62% (16/26) for peak flexion torque. Supination and flexion endurance was 90% of the contralateral arm in 81% (21/26) and 65% (17/26) of subjects, respectively. Ten subjects (39%) achieved 90% strength of the contralateral arm on at least four of five strength tests. Eight of the 26 patients were evaluated pre- and post-surgery. As compared to the contralateral limb, chronic distal biceps rupture was found to have a mean [95%CI] deficit in peak supination torque of 31.0 [21.0, 42.9]% (p=0.002). Mean deficit in peak flexion torque of 34.2 [23.1, 45.4]% (p <0.001). Reconstruction resulted in an increase in peak supination torque of 33.5 [8.7, 58.3]% (p=0.0162), increase in peak flexion torque of 35.0 [6.4, 63.6]% (p=0.023), increase in isometric strength of 57.6 [36.1, 79.1]% (p<0.001), increase in supination endurance of 0.6 [-22.2, 23.4]% (p=0.668), and a decrease in flexion endurance of 4.8 [-23.3, 13.7](p=0.478). Ninety-six percent of the patients (25/26) were satisfied, or very satisfied with the overall outcome of the surgery, while median Mayo score post-reconstruction was 100 (range: 55–100). Chronic distal biceps tendon rupture results in less supination loss and greater flexion loss than previously reported. Reconstruction with tendon graft results in a significant, but incomplete recovery of peak supination and flexion torque, but no significant change in endurance. Clinical patient satisfaction with surgical outcomes is high

We present a review of claims made to the NHS Litigation Authority (NHSLA) by patients with conditions affecting the shoulder and elbow, and identify areas of dissatisfaction and potential improvement. Between 1995 and 2012, the NHSLA recorded 811 claims related to the shoulder and elbow, 581 of which were settled. This comprised 364 shoulder (64%), and 217 elbow (36%) claims. A total of £18.2 million was paid out in settled claims. Overall diagnosis, mismanagement and intra-operative nerve injury were the most common reasons for litigation. The highest cost paid out resulted from claims dealing with incorrect, missed or delayed diagnosis, with just under £6 million paid out overall. Fractures and dislocations around the shoulder and elbow were common injuries in this category. All 11 claims following wrong-site surgery that were settled led to successful payouts.

This study highlights the diagnoses and procedures that need to be treated with particular vigilance. Having an awareness of the areas that lead to litigation in shoulder and elbow surgery will help to reduce inadvertent risks to patients and prevent dissatisfaction and possible litigation.

Cite this article: Bone Joint J 2014; 96-B:574–9.

Our study aims to demonstrate the efficacy of using endobutton and interference screw technique in the repair of acute distal biceps ruptures. From April 2009 to May 2013, 25 consecutive patients had acute distal biceps tendon repairs using an endobutton and interference screw technique. 3 patients were lost to follow up leaving 22 patients available for review. Mean follow up was 24 months(1–51). All were evaluated using a questionnaire, examination, radiographs, power measurements, and Oxford Elbow and MAYO scores. Overall 95% patients (21/22) felt that their surgery was successful and rated their overall experience as excellent or good. Mean return to work was at 100 days(0–280) and mean postoperative pain relief was 23 days(1–56). 55% returned to sport at their pre-injury level. There was one case (4.5%) of heterotopic calcification with 3 superficial infections(14%). There were no intra or postoperative radial fractures, metalwork failures or metalwork soft tissue irritations. Mean pre-operative Oxford Elbow Scores were 18(6–37) and post operative 43(24–48) (p<0.00001). Mean pre-operative Mayo scores were 48(5–95) and post-operative were 95(80–100)(p<0.00001). Our study supports that distal biceps repairs using the endobutton and interference screw technique appears to lead to high patient satisfaction rates with a relatively early return to function